Thursday, April 26, 2012

What is critical psychiatry?

A comment on a previous post asked me what critical psychiatry is. Perhaps I should make an attempt to provide an answer in summary form. The Wikipedia entry is informative for those that are interested. Or, if you really want to read more about the subject, there's always my edited book. (Get it from a library rather than buying it.)

I've always said the essential message is that psychiatry can be practiced without taking the step of faith of believing that mental illness is due to brain pathology, such as a chemical imbalance in the brain. This is commonly what patients are told, but the evidence is against it. Don't misunderstand what I'm saying. Of course mental illness must show through the brain - but not necessarily in the brain. There are implications for both assessment and treatment in practice. Diagnosis is not about finding an entity of some kind, but about providing understanding. We also need to be more sceptical about treatments, such as medication.

11 comments:

To me critical psychiatry is eliminating the political and rhetorical aspects of the field and focusing on what is known and what is not known. A good example would be the critique of donepezil several years ago by a prominent psychopharmacologist who concluded that there was very little gained particularly for the expenditure. That was a striking analysis that received no play in the American press.

The current hot topic in the US has to do with the "epidemic" of opioid use and the associated deaths by accidental overdose. This occurs about a decade after widespread criticism that chronic pain was inadequately treated and that more opioids could be used for chronic nonmalignant pain.

The press coverage in the situation with opioids is sensational due to political and rhetorical dimensions that tend toward the extreme positions of opioids or no opioids.

Thank you for both the explanations about 'critical psychiatry'I hope my library hold a copy of 'critical psyc: the limits of madness.'This is where I don't get it. If evidence is against the neuro-chemicals imbalance within the brain theory ( from the previous post comment)- why are so many people still taking tablets such as antipsychotic drugs or anti depression where their main mechanism of action are through inhibit or stimulate the neurochemical pathways. Are those drugs unnecessary??

Not necessarily. There's pretty good evidence that anti-depressants (for instance) work as an elaborate placebo in the vast majority of cases.

If I have this right, when we look at all the data - which now includes previously unpublished negative trials hidden by the drug industry - anti-depressants tend to perform just better than placebo. However, when you consider that the treatment group will go on to experience side-effects that the placebo group doesn't, this will in effect cause some to 'break blind' (i.e. realise they're receiving an active drug) which probably goes on to affect their outcomes over and above any medicinal effect. On similar trials on non-antidepressant products, but with the same side-effect profile, these non-psychiatric drugs seem to perform at a similar level to their psychiatric counterparts.

As for psychiatric medication as a whole, I'd recommend Joanna Moncrieff's drug-centred model of psychiatric treatment, which I think at least allows us to be honest and scientific about the pros, cons and actions of psychopharmacy (alongside other interventions).

Just a quick note on your question. I don't know why the mechanism of action of a psychiatric drug has a different standard than a nonpsychiatric drug. Having extensive experience with both, I spend a good deal of my time explaining the effects and side effects of both and providing people with the most accurate and up to date information on the potential side effects. I would say that about one person in 20 does not want printed information, but most people take what I provide and do additional research on the Internet.

By the time a person sees a psychiatrist in the US they have usually tried many other approaches. I think that their decision is really made on the basis that they have a significant problem and they are willing to put up with some degree of risk in order to solve it. We discuss ways to keep that risk to a minimum.

I don't think that the mechanism of action of the medication comes into play and I don't think it is any more relevant than the mechanism of action of non-psychiatric medications. The first time I heard about "chemical imbalance" was about 30 years ago. I had just finished reading an article in Science magazine about the regulation of stress hormones. The "chemical imbalance" theory struck me as a crude metaphor at best and certainly not an explanation of anything.

I think your question also addresses the issue of why study mechanisms at all? You can pick up many psychiatric journals these days like Biological Psychiatry and read about many mechanisms. Many people view that as reductionist, I see it as one way to understand complexity. Psychiatrists in general have been leaders in using the qualifier "heuristic" when discussing many of these matters. You don't see that term used by other specialities whose explanations gradually change over time.

I think that there are several clear reasons for taking a medication, even in the case where it causes noticeable side effects. The commonest one I have observed over time is not wanting to have another episode of illness whether that is depression, psychosis, or atrial fibrillation.

All our choices have individual costs, whether we take medication all of the time, some of the time or not at all. Value judgements are attached to each position by others [health & social care providers, allies, activists, survivors]. From believing it to be imperative through to lazy for taking it, from lacking in 'insight' for taking it or not taking it through to distress not existing or being 'serious' enough unless taking it - there are many shades of judgement from everyone including peers as to what constitutes a 'good' decision. When I first publicly spoke about Schizophrenia and drugs in the 80's before the development of the HVN I took a lot of flak for suggesting that we should have full BNF level of information and the choice to manage difficulties without medication. Carers and service users who took medication would tell me I was "lucky" I could live without meds or I couldn't be 'that bad'. They were not aware that I had been told I should have remained on depot injections 'for life' at 19 yrs of age and that walking away was not easy for me but I couldn't live with the side effects. I decided for me that drug effects were less tolerable to me than my voices. I'd actually rather die with my voices than on daily medication, but that doesn't mean I'm unwilling to ever take anything for short periods because I do. I've been down for that too! I had NSF activists jump up and cry 'you're telling people to stop taking their medication!' and I wasn't, I never have. It has to be an individual decision and I have no more right to tell someone to take it or not take it than anyone else, I just insist on full information, choice, alternatives and that meds shouldn't automatically be the 1st line of treatment. What really pains me is that lip service is paid to The Effects [side effects are euphemism]. As a friend said to her Home Treatment consultant 'what the hell do you know about how it is for me having gained 2 stone from Clozapine as a tall thin man?'. Weight gain is not taken seriously and the 'benefits outweigh the side effects' argument is utter wank unless the person taking it is saying that. There is a denial within services that antipsychotics cause weight gain because of metabolic changes to glucose metabolism so it's grossly unfair for service users to be given diet sheets when for some that weight doesn't shift no matter how healthily they eat until they come off the drug. It's as though ANY effect is supposed to be 'worth it' and no it bloody well isn't when you see someone actively suicidal because of those effects. Psychiatrists often miss the fact they may make a person look or feel calmer but the same thoughts/feelings/perceptual differences are still there! Then if the person doesn't 'respond' it's their fault, their intractability, or it's pronounced as PD [contemporary description of incurable/untreatable, or 'proof' that psychosis cannot have existed in the first place]However, looking at pharmacology, I don't understand why [puts on body armour] greater use is not made of benzodiazepines for short periods for anxiety reduction in acute periods because these are less damaging to the brain in my view.

Diabetes is a disease with adverse effects especially if not controlled regularly. This explains why it can be an expensive ailment as well. This is the reason why insurance companies are currently certifying the use of talking glucose meter.

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